Vertebral Artery Stenting With Flow Reversal

Abstract

A 47-year-old man was admitted with recurrent symptoms of dysarthria, diplopia, vertigo, and drop attacks. Workup revealed >90% stenosis of the left vertebral artery at its origin with poststenotic dilatation (Fig 1). The vertebral artery was 4 mm in diameter. The plaque appeared to have significant embolic potential. The right common femoral artery was accessed with short 9F sheath, and patient was anticoagulated with intravenous heparin (100 U/kg body weight). The left subclavian artery was cannulated using headhunter catheter. The catheter was advanced over the wire to mid brachial artery. Wire exchanged to stiff wire. MoMa flow reversal guide catheter (Medtronic, Minneapolis, Minn) was advanced over the stiff wire until the trailing balloon was engaged in the left subclavian artery. The leading balloon was positioned in left subclavian artery and kept deflated. The trailing balloon in left subclavian artery was inflated after making sure that activated clotting time was >250 seconds. An angiogram was performed to ensure that there was no antegrade flow in left vertebral artery (Fig 2). Spartacore 0.014 wire (Abbott Labs, Abbot Park, Ill) was introduced through the working port of MoMa guide catheter and was used to cross the area of near occlusive stenosis in proximal part of left vertebral artery. The lesion was successfully stented open with 4- × 18-mm Herculink Elite (Abbott Labs) balloon-expandable stent (Fig 3). The stent was projected in the left subclavian artery for about 1 mm. The stented segment of vertebral artery was aspirated multiple times with Export catheter (Medtronic). A significant amount of atherosclerotic debris was aspirated (Fig 4). Antegrade blood flow was restored. The MoMa device balloon in subclavian artery was deflated. Completion arteriogram revealed brisk flow in left vertebral artery, without any residual stenosis. The patient remained stable, without any adverse neurologic events. Sheath and guiding catheter was removed and hemostasis secured. The 60-day follow-up revealed multiphasic flow in the left vertebral artery and patient remained symptom free. View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Vertebral artery stenting with flow reversal as embolic protection is very safe and effective strategy for endovascular vertebral artery interventions in select group of patients.